High-Risk Patient Care Navigator

CMPI Coastal Medical Physicians, Inc., d/b/a Brown Health Medical Group Primary Care; United States; On-site; USD 29,000 - 48,000; Full time

Job summary

Brown University Health is seeking a Nurse Care Manager to support the Nurse Care Management department in Providence, RI. The role focuses on rising-risk and high-risk patients, coordinating care, and ensuring adherence to care plans under the NCM guidance.

Interventions include telephonic outreach, care plan development, and documenting all activities in the EMR, while partnering with community resources to meet patient needs and promote safety and health outcomes.

Responsibilities

• Screens patient census using provided criteria to determine if the patient should be categorized as high risk
• Manages the high-risk patient census to assess if intervention from the Nurse Care Manager (NCM) or other disease management/population health program is needed
• Assesses patients for basic needs and intervenes when appropriate, referring patients with greater needs to the NCM for intervention
• Works closely with the NCM to help patients reach their goals, maintain safety and improve their health
• Has awareness and understanding of community and BHMGPC resources/teams to offer patients
• Hands off communication to the NCM or other BHMGPC program when necessary
• Works with the NCM to develop and update patient care plans and attends care conferences and huddles as needed
• Performs telephonic and remote patient outreach to patients, documenting all outreach and interventions in the electronic medical record (EMR)
• Facilitates and reinforces patient self-management under the direction of the NCM and encourages patients to keep up to date with labs, PCP and specialist visits and their care plan
• Evaluates for patient safety
• Ensures documentation is collected from patient specialist visits
• Provides resources and disease management education to patients
• Comfortable with MOLST and durable power of attorney forms to lightly discuss with patients
• Understands durable medical equipment (DME) needs and referrals
• Has in-depth understanding of medical insurances and benefits
• Assists patients with transportation needs
• Performs other job-related duties as assigned

Job description

Brown University Health is seeking a Nurse Care Manager to support the Nurse Care Management department in Providence, RI. The role focuses on rising-risk and high-risk patients, coordinating care, and ensuring adherence to care plans under the NCM guidance.

Interventions include telephonic outreach, care plan development, and documenting all activities in the EMR, while partnering with community resources to meet patient needs and promote safety and health outcomes.